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Updated May 04, 2023

A medical power of attorney form allows a person (principal) to select an agent to make healthcare decisions on their behalf. The agent’s powers are effective after the principal becomes incapacitated and cannot make decisions on their own. This must be verified, in writing, by the attending physician.

When making decisions, the agent must follow the preferred treatment options written in the principal’s living will. If one is not available, the agent will have the freedom to make any decision.

Signing Requirements – Depends on the State where the principal resides.

When is an Agent able to make medical decisions?

An agent can make medical decisions “when the primary physician certifies in writing that the principal lacks capacity.”

Source: UHCDA Section 2, Part B

What is a Medical Power of Attorney?

A medical power of attorney (MPOA) is an official document that designates an agent or attorney-in-fact to make healthcare decisions on the principal’s behalf. A dispute on whether the principal can make their own decisions will only go into effect after a licensed physician has deemed the principal incapacitated.

It’s recommended for anyone making a medical power of attorney to also create a living will, which allows them to outline their treatment preferences for an agent to follow.

Medical POA vs. Living Will

A medical power of attorney lets a person select their preferred treatment options with the use of an agent to carry out their wishes. The agent will have full authority to make any type of decision to prolong or withdraw life-sustaining treatment.

A living will allows a person to select their preferred treatment options without the use of an agent. A living will directs medical staff to prolong or withdraw life-sustaining treatments depending on their condition.

Statutory Forms

STATE	STATUTORY FORM	LAWS
Alabama	Advance Directive for Health Care	§ 22-8A-4(c)(4)
Alaska	Advance Health Care Directive	AS 13.52.010
Arizona	Health Care Power of Attorney	§ 36-3224
Arkansas	Durable Power of Attorney for Health Care	§ 20-6-103
California	Advance Health Care Directive	PROB § 4701
Colorado	Medical Durable Power of Attorney	§ 15-14-506
Connecticut	Appointment of Health Care Representative	Sec. 19a-575a
Delaware	Advance Health Care Directive	§ 2505
Florida	Designation of Health Care Surrogate	§ 765.202(1)
Georgia	Advance Directive for Health Care	§ 31-32-4
Hawaii	Advance Health Care Directive Form	§ 327E-16
Idaho	Living Will and Durable Power of Attorney for Health Care	§ 39-4510
Illinois	Durable Power of Attorney for Health Care	755 ILCS 35/3(b)
Indiana	Health Care Representative Appointment	755 ILCS 45/Art. IV
Iowa	Durable Power of Attorney for Health Care Decisions	§ 144B.5
Kansas	Durable Power of Attorney for Healthcare Decisions	§ 58-632
Kentucky	Advance Directive	§ 311.629
Louisiana	Medical Power of Attorney	RS 28:223
Maine	Health Care Advance Directive Form	§ 5-805
Maryland	Advance Directive	§ 5-603
Massachusetts	Health Care Proxy	§ 201D-2
Michigan	Durable Power of Attorney for Health Care	§ 700.5501(b)
Minnesota	Health Care Directive	§ 145C.16
Mississippi	Advance Health Care Directive	§ 41-41-209
Missouri	Durable Power of Attorney for Health Care	§ 404.822
Montana	Durable Power of Attorney for Health Care	§ 53-21-1304
Nebraska	Power of Attorney for Health Care	§ 30-3404
Nevada	Durable Power of Attorney for Healthcare Decisions	NRS 162A.860
New Hampshire	Advance Directive	Section 137-J:20
New Jersey	Medical Power of Attorney (proxy)	§ 26:2H-57
New Mexico	Advance Directive for New Mexico	§ 24-7A-4
New York	Health Care Proxy	PBH § 2981
North Carolina	Health Care Power of Attorney	§ 90-321
North Dakota	Health Care Directive	§ 23-06.5-17
Ohio	Health Care Power of Attorney	Section 1337.17
Oklahoma	Advance Directive for Health Care	§ 63-3101.4
Oregon	Advance Directive for Health Care	ORS 127.527
Pennsylvania	Durable Health Care Power of Attorney	§ 5471
Rhode Island	Durable Power of Attorney for Healthcare	§ 23-4.10-2
South Carolina	Health Care Power of Attorney	§ 62-5-504
South Dakota	Durable Power of Attorney for Health Care	§ 59-7-2.1
Tennessee	Advance Directive for Health Care	§ 68-11-1803(b)
Texas	Durable Power of Attorney for Health Care	§ 166.161
Utah	Advance Health Care Directive	§ 75-2a-117
Vermont	Advance Directive for Health Care	18 V.S.A. § 9703
Virginia	Advance Medical Directive	§ 54.1-2984
Washington	Durable Power of Attorney for Health Care	§ 11.125.100
West Virginia	Medical Power of Attorney	§ 16-30-4
Wisconsin	Power of Attorney for Health Care	§ 155.30
Wyoming	Advance Health Care Directive	§ 35-22-403

Signing Requirements

A witness cannot be a person who is related to the principal or the agent, or be a beneficiary in the principal’s last will and testament. If a notary is required, the notary may not act as a witness.

STATE	SIGNING REQUIREMENTS	LAWS
Alabama	Two (2) Witnesses	§ 22-8A-4(c)(4)
Alaska	Notary Public or Two (2) Witnesses	AS 13.52.010(b)
Arizona	Notary Public or One (1) Witness	§ 36-3221(A)(3)
Arkansas	Notary Public or Two (2) Witnesses	§ 20-6-103(c)
California	Notary Public or Two (2) Witnesses	§ 4701(e)
Colorado	No law (Notary Public recommended)	§ 15-14-506
Connecticut	Two (2) Witnesses	§ 19a-575
Delaware	Two (2) Witnesses	§ 2503(b)(1)(d)
Florida	Two (2) Witnesses	§ 765.202(1)
Georgia	Two (2) Witnesses	§ 31-32-5
Hawaii	Notary Public and Two (2) Witnesses	§ 327E-3(1)
Idaho	No law (Notary Public recommended)	§ 39-4510
Illinois	One (1) Witness	755 ILCS 45/4-5.1
Indiana	One (1) Witness	§ 16-36-1-7(b)(3)
Iowa	Notary Public or Two (2) Witnesses	§ 144B.3(b)
Kansas	Notary Public and Two (2) Witnesses	§ 58-632
Kentucky	Notary Public or Two (2) Witnesses	§ 311.625(2)
Louisiana	Two (2) Witnesses	§ 224 (A)
Maine	Two (2) Witnesses	§ 5-803(2)
Maryland	Two (2) Witnesses	§ 5–603
Massachusetts	Two (2) Witnesses	§ 201D-2
Michigan	Two (2) Witnesses	§ 700.5506(4)
Minnesota	Notary Public or Two (2) Witnesses	§ 145C.03(5)
Mississippi	Notary Public or Two (2) Witnesses	§ 41-41-205(2)
Missouri	Notary Public	§ 404.705(3)
Montana	Two (2) Witnesses	§ 50-9-103
Nebraska	Notary Public or Two (2) Witnesses	§ 30-3404(5)
Nevada	Notary Public or Two (2) Witnesses	NRS 162A.790
New Hampshire	Notary Public or Two (2) Witnesses	§ 137-J:14
New Jersey	Notary Public or Two (2) Witnesses	§ 26:2H-56
New Mexico	Two (2) Witnesses	§ 24-7A-4
New York	Two (2) Witnesses	PBH § 2981(2)
North Carolina	Notary Public and Two (2) Witnesses	§ 32A-16A(3)
North Dakota	Notary Public or Two (2) Witnesses	§ 23-06.5-05(d)
Ohio	Notary Public or Two (2) Witnesses	§ 1337.12(1)(b)
Oklahoma	Two (2) Witnesses	63 O.S. § 3101.4(A)
Oregon	Notary Public or Two (2) Witnesses	§ 127.515(2)
Pennsylvania	Two (2) Witnesses	§ 5452(b)(2)
Rhode Island	Notary Public or Two (2) Witnesses	§ 23-4.10-2(9)
South Carolina	Notary Public and Two (2) Witnesses	§ 62-5-517
South Dakota	Notary Public or Two (2) Witnesses	§ 34-12D-2
Tennessee	Notary Public or Two (2) Witnesses	§ 34-6-203(a)(3)
Texas	Notary Public or Two (2) Witnesses	§ 166.154
Utah	One (1) Witness	§ 75-2a-107(c)
Vermont	Two (2) Witnesses	§ 9703(b)
Virginia	Two (2) Witnesses	§ 54.1-2983
Washington	Notary Public or Two (2) Witnesses	§ 70.122.030
West Virginia	Notary Public and Two (2) Witnesses	§ 16-30-4(a)
Wisconsin	Two (2) Witnesses	§ 155.10(1)(c)
Wyoming	Notary Public or Two (2) Witnesses	§ 35-22-403(b)

How to Get Medical POA (4 steps)

Step 1 – Select Your Agent
Step 2 – Agent’s Decisions
Step 3 – Attach a Living Will
Step 4 – Sign and Complete

Step 1 – Select Your Agent

The agent that you select will have the responsibility of making your decisions based on your healthcare situation. Therefore, it’s recommended to select a person you trust and is aware of your basic medical history (such as heart conditions, medication, allergies, etc.)

Successor (2nd) Agent – An individual selected only if the primary agent is not able to fulfill their duties. Co-agent authority is not usually allowed; it must be the decision of one person.
Compensation – The principal has the option to set up compensation for the agent selected for lodging, food, and travel costs.

Step 2 – Agent’s Decisions

The decisions you give your agent related to your healthcare are up to you. You can allow your agent to make any type of decision that presents itself or you could limit your agent to only certain types of decision-making. The more detailed you are as to what your agent can and cannot do will enhance the medical staff on your intentions.

Example – Requesting the agent to refuse life support if there is little to no chance of a full recovery.

The following powers of the agent should be written:

Surgical treatments
Nursing home treatment/care
Hospitalization
Medical treatment
Psychiatric treatment
Homestay care
Organ donation
End-of-life decisions

Step 3 – Attach a Living Will

A living will is highly recommended to be attached to any medical power of attorney. In addition to having someone speak on one’s behalf, a living will outlines a person’s end-of-life treatment selections.

For example, if a person should become incapacitated with no chance of a cure, they can select to withhold life-sustaining methods that would keep them medically alive. In addition, it allows the selection of organ donation and other post-death options.

Step 4 – Sign & Complete

The principal and agent must sign in accordance with their respective state signing laws. In most cases, the form may be signed in the presence of two witnesses or a notary public, sometimes both. After this has been legally authorized, the document becomes valid for use. The principal must be thinking freely during the creation of this form.

The agent should carry an original copy of their form and will most likely need to present it during every occurrence. It is recommended to give a copy of this form to your primary care physician.

Sample

MEDICAL POWER OF ATTORNEY

1. APPOINTMENT OF HEALTH CARE AGENT

I, [PRINCIPAL NAME] of [ADDRESS], City of [CITY], State of [STATE] (HEREINAFTER known as the “Principal”) hereby appoint, [AGENT NAME] of [ADDRESS], City of [CITY], State of [STATE] (HEREINAFTER known as the “Agent”) as my Agent to make any and all medical decisions on my behalf, except to the extent I limit those decisions in this document. This power of attorney takes effect if my doctor certifies in writing that I can no longer make my own health care decisions. My agent can be reached at the following contact information:

Home Phone:[PHONE] Work Phone: [PHONE]

Cell Phone: [PHONE] E-Mail: [EMAIL]

2. LIMITATIONS OF MY AGENT

My agent is authorized to make all medical decisions on my behalf EXCEPT for the following: [LIST LIMITATIONS]

3. APPOINTMENT OF ALTERNATE AGENT

If my agent appointed above is unable or unwilling to serve as my agent, I appoint the following person(s) to serve as agents in the order set forth below with the authority to make health care decisions on my behalf as provided herein:

a. First Alternate Agent

Name: [NAME] Address: [ADDRESS] Phone: [PHONE]

b. Second Alternate Agent

Name: [NAME] Address: [ADDRESS] Phone: [PHONE]

4. ORIGINAL AND COPIES OF THIS DOCUMENT

The original document is/will be filed in the following place: [LOCATION]

I have/will provide copies of my medical power of attorney to the following: [NAME(S)]

5. DURATION

Unless stated otherwise herein, this document shall remain in effect until I revoke it. I understand that I cannot revoke this document during the time I am considered incompetent to make my own decisions.

(If applicable Initial and Check)

________ ☐ (OPTIONAL) This power of attorney shall expire on [DAY] of [MONTH], [YEAR].

6. PRIOR MEDICAL POWER OF ATTORNEY

By signing this document, I hereby revoke any and all prior medical powers of attorney that I may have executed.

7. EXECUTION

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC

YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES NOT RELATED BY BLOOD OR MARRIAGE.)

SIGNATURES

I /We hereby execute this document on [DAY] of [MONTH], [YEAR] in the City of [CITY], State of [STATE].

Principal’s Signature: _____________________ Print Name: ______________________

Agent’s Signature: _____________________ Print Name: ______________________

1^st Alt. Agent’s Signature: ____________________ Print Name: ______________________

2^nd Alt. Agent’s Signature: ____________________ Print Name: ______________________

NOTARY ACKNOWLEDGMENT

STATE OF [STATE]

[COUNTY] County, ss.

On this [DAY] of [MONTH], [YEAR], before me appeared [NAME], as Maker of this Medical Power of Attorney who proved to me through government-issued photo identification to be the above-named person, in my presence executed foregoing instrument and acknowledged that (s)he executed the same as his/her free act and deed.

Notary Public: _____________________

Print Name: _____________________

My commission expires: _____________________

(seal)

WITNESS STATEMENT AND ACKNOWLEDGMENT

I am not the person appointed as agent or successor agent in this medical power of attorney. I am not related to the maker of this document by blood or marriage. I am not entitled to any portion of the maker’s estate, nor do I have any claim against the maker’s estate. I am not the attending physician of the maker or an employee of the attending physician. I am not involved in providing direct patient care to the maker and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.

SIGNATURE OF FIRST WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

SIGNATURE OF SECOND WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

For the comprehensive document, please download the free form or hit “create document.”